A patient was admitted to the surgical unit after surgical ...

[mydiamond]

A patient was admitted to the surgical unit after surgical removal of an abdominal tumor. As the nurse performs a postsurgical assessment, the patient's blood pressure is 90/54, heart rate is 94, and respiratory rate is 22 .
 
  Based on these values, the nurse should be most concerned with which of the following conditions? a. Hypovolemia
  b. Left-sided heart failure
  c. Right-sided heart failure
  d. Hypervolemia

Question 2

A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation. The nurse charts the following: Discuss alternatives for pain control. Which component of SOAP did the nurse chart?
 
  a. S
  b. O
  c. A
  d. P

[momtoalll]

Answer to Question 1

A
Hypovolemia is a reduced circulating blood volume resulting from extracellular fluid losses that occurs in conditions such as shock and severe dehydration. If the fluid loss is significant, the body tries to adapt by increasing the heart rate and constricting peripheral vessels to increase the volume of blood returned to the heart and increase the cardiac output. The patient is experiencing shock (low blood pressure, increased pulse and respirations). Left-sided heart failure is characterized by impaired functioning of the left ventricle. This is usually caused by increased preload (fluid volume overload) or afterload (increased systemic vascular resistance such as hypertension). Right-sided heart failure results from impaired functioning of the right ventricle, which is typically caused by pulmonary disease or pulmonary hypertension. Fluid volume overload or hypervolemia may lead to vascular congestion in patients with heart, kidney, or lung diseases. The patient has lost fluid, not gained fluid.

Answer to Question 2

B
Discuss alternatives for pain control is a Plan. SOAP is an acronym for the following:
S: Subjective data (verbalizations of the patient)
O: Objective data (data that are measured and observed)
A: Assessment (diagnosis based on the subjective and objective data)
P: Plan (what the caregiver plans to do)